From the Guidelines
Elective repair of abdominal aortic aneurysm (AAA) is recommended if the AAA diameter is ≥55 mm in men or ≥50 mm in women, as stated in the 2024 ESC guidelines for the management of peripheral arterial and aortic diseases 1. The guidelines for AAA repair prioritize reducing peri-operative morbidity and mortality, and the choice of repair method depends on patient anatomy, age, and comorbidities. Key considerations include:
- Elective repair is recommended for AAA diameters ≥55 mm in men or ≥50 mm in women 1
- Endovascular repair is recommended over open repair for ruptured AAA with suitable anatomy 1
- Prior to AAA repair, DUS assessment of the femoro-popliteal segment should be considered to detect concomitant aneurysms 1
- EVAR should be considered as the preferred therapy for patients with suitable anatomy and reasonable life expectancy (>2 years) 1
- Regular follow-up imaging is essential, with CT scans at 1 month, 6 months, and annually thereafter for EVAR patients 1 The 2024 ESC guidelines provide the most recent and highest-quality evidence for AAA repair, and their recommendations should be followed to optimize patient outcomes. In patients with unruptured AAA, the decision to repair should be based on the balance between the risk of rupture and the risk of surgical complications, taking into account the patient's overall health and life expectancy. The guidelines emphasize the importance of individualized decision-making and shared decision-making between patients and healthcare providers. Overall, the guidelines aim to prevent catastrophic rupture while balancing surgical risks against the natural history of aneurysm progression.
From the Research
Guidelines for Abdominal Aortic Aneurysm (AAA) Repair
The guidelines for AAA repair are based on various factors, including the size of the aneurysm, the patient's overall health, and the risk of rupture.
- The size of the aneurysm is a critical factor in determining the need for repair. Aneurysms larger than 5.5 cm in diameter are typically recommended for repair 2.
- The patient's overall health and surgical risk also play a significant role in determining the best course of treatment. Patients with low surgical risk may be recommended for open surgical repair (OSR), while those with high surgical risk may be recommended for endovascular aneurysm repair (EVAR) 3.
- The risk of rupture is also an essential consideration. Aneurysms with a high risk of rupture may require immediate repair, regardless of the patient's overall health 4.
Treatment Options
There are two primary treatment options for AAA repair: open surgical repair (OSR) and endovascular aneurysm repair (EVAR).
- OSR is a traditional surgical approach that involves making an incision in the abdomen to repair the aneurysm. This approach is often recommended for patients with low surgical risk and aneurysms that are not too large 3.
- EVAR is a minimally invasive approach that involves using a catheter to deliver a stent-graft to the aneurysm. This approach is often recommended for patients with high surgical risk or aneurysms that are too large for OSR 5, 2.
Recommendations
Based on the available evidence, the following recommendations can be made:
- OSR is recommended for low-risk patients up to 80 years old 3.
- EVAR is recommended for low-risk patients older than 80 years, high-risk patients, and patients with aneurysms that are not anatomically feasible for OSR 3.
- Regular and long-term follow-up with imaging is mandatory after EVAR to monitor for complications such as endoleaks 6.
- Patients who are less likely to comply with follow-up imaging are less favorable EVAR candidates 6.